1 NEPAB M&M: Trauma in PregnancyDecember 6, 2016 Tim Hutchison, MD FACEP

2 Objectives At the conclusion of this presentation, the participant should be able to: 1. Analyze clinical, radiologic, laboratory and response data to increase efficiencies and determine systemic modalities that will increase quality patient care. 2. Apply evidence based guidelines for optimal pre-hospital care and quality patient outcomes. 3. Communicate clinical situations effectively with providers in the pre-hospital and hospital settings. (911 responders, critical access hospitals, transport teams and tertiary care centers)

3 Disclosure Dr. Hutchison and all others in control of the content of this activity have reported no relevant financial relationships that create a conflict of interest for CME purposes

4 Air Link Course Arrived on scene 18 minutes before extraction by stokes basket up embankment with rope belay system Report that SROM and UC were 7 minutes apart and lasting 15 sec. each 0130 hour and 10° F Alert, GCS-15, HR-108, BP-104/63,RR-20, 98% RA G3P2, good prenatal care, full term 40+ weeks, no complications and on PNV Last delivery was “very fast”, but denied sensation to push

5 Air Link Course C/O constant low back pain worse with movementPE: Tender upper L spine, soft NT uterus and no VB 9 minute flight to MCR, Ready Heat blanket, A/C heater on high and warm NS 400 infused VS: 118/76, 95, 20 98% on NRB Discussed getting FHT with Doppler Limited Trauma called with request for OB Team

6 MCR Course ED, OB physician and L&D RN with fetal monitor on arrivalVS: 124/69, 112, 22, 97.1°F, 89% on RA PE: + for upper lumbar tenderness, LE neuro intact, uterus NT, no VB, c-spine cleared clinically FAST: alive fetus w/ FHR 135, no FF in RUQ,LUQ and pelvis; SROM OB monitoring: FHR-132, variability-moderate, decels-absent; Uterine- q2-4 min, duration 40-80 SVE: Cx-5cm, 80% effaced, -3 station, vertex

7 MCR Course Imaging: CXR and lateral T&L spine doneL1 burst fracture with significant angulation and off-set Trauma and Neurosurgery Consulted Husband was a Trauma Arrest and pronounced at PVH

8

9 MCR Course Labs: CMP- CO2 was 19, O+, CBC-WNLTaken for stat C-section because of unstable L1 fracture and risk of laboring Healthy FT male infant w/o trauma delivered No other intra-abdominal trauma noted

10 MCR Course & Follow Up MRI spine: L1, 50% compression fracture with mod-severe spinal stenosis and 8mm retropulsion into canal Later same day went for open reduction and T11-L3 fusion Spiritual Care Counseling provided Discharged 1/18/16 neuro intact Follow up 7/16 was doing well, neuro intact and not needing chronic pain meds

11 Chance Fractures First described by G. Q. Chance in 1948Caused by violent forward flexion Compression injury to anterior portion of vertebrae and flexion distraction injury to posterior elements T12-L2 most common in adults Kids can be lower L spine Lap belt only 50% of fractures have associated intra-abdominal injuries i.e. solid organs, duodenum, mesentery, pancreatic Neurologic deficits are rare Some controversy on operative vs non-operative care

12 Literature on Non-operative Management of Thoracolumbar Burst FracturesAuthor (year) No. of patients Average follow-up Neurological deterioration Kyphosis Pain at follow-up Functional status Mumford (1993) 41 2 years 1 case (radicular) 8% progression of body collapse 88% excellent to fair outcome relative to pain 90% satisfactory work status Weinstein (1988) 42 20 years None Kyphosis of 26o in flex, 17o in extension Average pain score 3.5 80% back to usual work Cantor (1993) 18 19 months Average of 1o progression (19o to 20o) 83% little or no pain 94% no restriction of activity Chan (1993) 20 3.9 years Average of 1.6o of progression (8oto 9.6o) 95% mild to no back pain 90% excellent outcome, all returned to work Chow (1996) 26 34 months Average of 2.3o of progression 79% little or no pain 75% return to usual work Shen (1999) 38 4 years Average of 4o progression (20o to 24o) 84% occasional or no pain 76% return to usual work Tropiano (2003) 45 Average of 1.2o progression 64% little or no pain 81% return to usual work Celibi (2004) 43 months Average of 8.3o ± 4.3o progression 73% occasional or no pain 77% return to previous work

13 Trauma in Pregnancy Best initial treatment priority is optimal resuscitation of the mother Physiologic changes of pregnancy i.e. delayed classic shock, IVC compression etc. Early involvement of Obstetrician and Fetal Monitoring if > weeks After primary survey/resuscitation of mother, fetal evaluation should be done before secondary survey of mother Fetus may be in jeopardy even with minor maternal injury i.e. decreased placental perfusion and/or abruption

14 Trauma in Pregnancy Rh immunoglobulin therapy if Rh negativeRisk benefit assessment for CT scans Placental abruption: severe constant pain, contractions, fetal distress, can be concealed Can be a difficult decision to deliver or not to deliver with multiple factors weighing in Perimortem C-section: success dependent on doing 5-6 minutes after arrest

15